Post-operative

CUES NURSING

DIAGNOSIS

RATIONALE OBJECTIVE NURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Medyo

masakit

yung sugat

ko kaya hindi

rin ako

masyadong

makakilos.

Since may

gamot

PAIN

(ACUTE)

Related to

surgical

incision

As

manifested

by

A disruption

in tissue

layer may

cause a

decrease

supply of

oxygen due

to decrease

blood

supply.

SHORT

TERM

GOAL:

After 15-30

minutes of

nursing

interventions,

the patient

will report

control of

DEPENDENT:

Administer analgesics as

ordered:

Nubain 1/2cc IVT q

4 PRN

INDEPENDENT:

Noted patient’s age,

coexisting medical/

psychological conditions,

idiosyncratic sensitivity

Relief of moderate to

severe pain.

Approach to

postoperative pain

management is based

on multiple variable

SHORT

TERM GOAL:

After 15-30

minutes of

nursing

interventions,

the patient

reported pain

was

controlled as

109

naman kaya

ko naman.”

Pain Scale

of 5 out of 10

Legend:

0 – absence

of pain

1 – 3 –mild

pain

4 – 6 –

moderate

pain

Subjective:

“Medyo

masakit

yung sugat

ko kaya hindi

rin ako

masyadong

makakilos.

Since may

gamot

naman kaya

ko naman.”

When blood

flow to a

tissue often

becomes

very painful

within a few

minutes.

Reference:

Medical

Physiology

By: Arthur C.

pain as would

be

manifested

by relaxed

appearance,

absence of

guarding and

a decreased

level of pain

scale of less

than 5

LONG TERM

to analgesics and

intraoperative

course(e.g., size/

location, drain

placement, anesthetic

agents used).

Evaluated pain regularly

(e.g., every 2hours x 12)

noting characteristics,

locations and intensity

(0-10 scale).

Emphasize patient’s

responsibility for

reporting pain/ relief of

factors.

Provides information

about need for/

effectiveness of

interventions.

It may not always be

possible to eliminate

pain; however,

analgesics should

evidence by

relaxed

appearance,

absence of

guarding

behavior and

a decrease

level of pain

to a scale of

110

7 – 10 –

severe pain

Objective:

-grimacing

-guarding

behavior(RU

Q)

Objective:

-grimacing

-guarding

behavior(RU

Q)

Guyton

11th Edition

page 599

GOAL:

After 2 days

of nursing

interventions,

the patient

will have

absence of

pain as would

be

manifested

by relaxed

appearance

and

restfulness,

pain completely.

Assessed vital signs,

noting tachycardia,

hypertension and

reduce pain to a

tolerable level. A

frontal and/or occipital

headache may develop

24-72 hours following

spinal anesthesia,

necessitating

recumbent position,

increased fluid intake

and notification of the

anesthesiologist.

Changes in these vital

signs often indicate

acute pain and

LONG TERM

GOAL:

UNABLE TO

RENDER

DUE TO

TIME

CONSTRAIN

TS (Ms. MD is

discharged

111

absence of

guarding

behavior and

irritability,

pain scale at

0.

increased respiration

even if patient denies of

pain.

Assessed causes of

possible discomfort

other than operative

procedure.

discomfort. Note: some

patients may have a

slightly lowered BP,

which returns to

normal range after pain

relief is achieved

Discomfort can be

caused/ aggravated by

presence of nonpatent

indwelling catheters,

NG tube, parenteral

lines (bladder pain,

gastric fluids and gas

accumulation and

already)

112

Reposition the client in

semi-fowler’s.

Provided backrub,

heat/cold applications as

infiltration of IV fluids/

medications.) May

relieve pain and

enhance circulation.

Semi-fowlers position

relieves abdominal

muscle tension,

Improves circulation,

reduces muscle

tension and anxiety

associated with pain.

Enhances sense of

well-being

113

additional comfort

measures

Encouraged use of

deep-breathing

exercises, guided

imagery, visualization,

music.

Relieves muscle and

emotional tension;

enhances sense of

control and may

improve coping

abilities.

CUES NURSING

DIAGNOSIS

RATIONALE NURSING

OBJECTIVES

NURSING

INTERVENTIONS

RATIONALE EVALUTION

OBJECTIVE: Problem:

Activity

If people may not

have the

SHORT TERM:

After 1 day of

INDEPENDENT: SHORT TERM:

After 1 day of

114

- Slowed

movement

- Body

malaise

SUBJECTIV

E:

“Medyo

nanghihina

pa ako, hindi

pa ako

masyadong

makakilos.”

Intolerance

Etiology:

R/T

generalized

weakness

Signs and

Symptoms:

As

manifested

by

OBJECTIVES

motivation or

energy to perform

activity some

clients who

undergone

surgery, client

may experience

more fatigue and

weakness that

are unable to

perform the task.

Reference:

Medical –

nursing intervention,

the client will be

able to participate

willingly in

necessary activities

as would be further

evidenced by

increased

movement/activities

by the client, as

verbalized by the

client, “Syempre

may anesthesia na

binigay sakin di ba,

Adjust activities or

things that will be

convenient to the

patient such as

letting her things

she needed be at

her bedside such

as her phone,

tissue water and

etc.

Reduce intensity

level of activities.

To prevent

over exertion.

To assist client

with

contributing

nursing

intervention,

the patient

participated

willingly in

necessary

activities as

evidenced by

moderate

movement as

the client

verbalized,

“Eto, tnatry ko

naman tumayo 115

:

-Pallor

- Slowed

movement

- Body

malaise

SUBJECTIVE

S:

“Medyo

nanghihina

pa ako, hindi

pa ako

masyadong

Surgical 4th

Edition vol.1

Joyce M. Black

and Esther

Matassarin

Jacobs p.440

Fundamentals of

Nursing 5th Edition

Barbara Kozier,

Glenora Erb,

Audrey Berman,

Shirlee Snyder

eto, medyo

nanghihina pa ako

kaya kailangan ko

pa ng mag-aalalay

sa akin for the mean

time.”

LONG TERM:

After 2 days of

nursing intervention,

the client will be

able to demonstrate

increase in activity

intolerance as would

Increase exercise

or activity level

gradually; Teach

method to

conserve energy,

such as stopping

for a minute to

take a rest when

factors and

manages

activities within

individual limit.

To assist client

to rearrange

activities within

individual

limits.

mag –isa. So

far kaya

naman,

humahawak

ako sa bed.”

LONG TERM:

UNABLE TO

RENDER

INTERVENTIO

N DUE TO

TIME

CONSTRAINT

S ( Ms. MD is 116

makakilos.” p. 734 be further

manifested by

absence of pallor,

tolerable movement,

absence of body

malaise.

walking.

Promote comfort

and provide for

relief of pain.

To enhance

ability to

participate in

activities.

discharged

already)

CUES NURSING

DIAGNOSIS

RATIONALE GOALS INTERVENTION RATIONALE EVALUATION

Subjective:

“Ito medyo

makirot.

Hindi ko pa

Impaired skin

integrity

Related to

mechanical

factors

Skin

(primary line of

defense against

bacterial infection)

Short term:

After 1 day of

nursing

intervention, the

patient will

Independent:

Encourage early

ambulation.

Promotes

circulation and

reduces risk

associated with

Short term:

After 1 day of

nursing

intervention, the

117

nga nakikta

tong sugat

ko kasi

may gasa

pa. ” as

verbalized

by the

patient

Objective:

-Disruption

of the skin

surface

due to the

surgical

(surigical

incision)

As manifested

by:

“Ito medyo

makirot. Hindi

ko pa nga

nakikta tong

sugat ko kasi

may gasa pa. ”

as verbalized

by the patient

-Disruption of

the skin

incised due to

surgical procedure

First line of defense

is lost

Strict adherence to

aseptic technique

during surgery and

in the days following

the procedure are

necessary to

compensate for the

promote healing

as evidenced by

Maintaining dry

and intact

incision site.

Long term:

After 1 month of

nursing

intervention, the

patient will be

able to :

Display that the

wound will be

totally healed

Use appropriate

padding device.

Collaborative:

Keep wound dry,

clean and carefully

dress wound,

support incision,

prevent infection

and stimulate

mobility.

Reduces

pressure and

enhances

circulation to

compromises

tissues.

Assists body’s

natural process of

repair

patient

promoted

healing as

evidenced by

Maintained dry

and intact

incision site.

GOAL MET

Long term:

118

incision

-Dry and

intact

wound

dressing

located at

RUQ

surface due to

the surgical

incision

-Dry and intact

wound

dressing

located at RUQ

impaired defense.

Reference:

Medical-Surgical

Nursing by Lemone

and Burke 1st

edition

and has no

more blood

discharge.

circulation to

surrounding areas.

Administer

Ciprobay 500mg 1

tab x 2 days PC

Inhibits bacterial

DNA synthesis

mainly by

blocking DNA

gyrase.

UNABLE TO

RENDER DUE

TO TIME

CONSTRAINTS

(Ms. MD is

discharged

already)

CUES NURSING

DIAGNOSIS

RATIONALE GOALS NURSING

INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE

: Patient

verbalized : “

Disturbed

Sleeping Pattern

related to

Hospitalization

can usually

disrupt sleep.

SHORT

TERM

GOAL :

INDEPENDENT

Discuss and explore with

the client’s relatives the

Identifying

possible causes

SHORT TERM

GOAL:

119

Nako

kailangan ko

nang umuwi,

tumataas

lang ang bili

ko dito, Hindi

tuloy ako

makatulog ng

maigi, saka

nagaalala

nadin ako sa

anak ko.”

OBJECTIVE :

unfamiliar

surroundings

and medical

management

practices.

As manifested by

patient

verbalized :

“Nako kailangan

ko ng umuwi,

tumataas lang

ang bili ko dito,

hindi tuloy ako

makatulog ng

This maybe

due to several

factors such

as loss of

familiar

surroundings,

fear of the

unknown,

disruption of

sleep because

of procedures

or treatment,

noise level of

After 30

minutes of

nursing

intervention,

the patient

will be able to

have a restful

sleep.

LONG TERM

GOAL :

After 2 days

of nursing

intervention,

possible causes that

contribute to discomfort

in surrounding

environment.

Render health teachings

on promoting restful

sleep to the relatives

such as:

a. Encourage the

patient or her

relatives to have

comforting hygienic

rituals such as

helps the nurse

and client plan

appropriate

interventions to

promote sleep

It promotes

relaxation of her

body as well as

the mind

After 30

minutes of

nursing

interventions

the patient had

been able to

have restful

sleep

GOAL MET

LONG TERM

GOAL:

UNABLE TO 120

-Yawning

-Presence

of dark

circles

around

the eyes.

-

Irritatable

maiagi, saka

nagaalala nadin

ako sa anak ko.”

-yawning

-presence of

dark circles

around the eyes

- irritable

privacy.

Hospitalization

is disruptive of

normal sleep

because of the

change in the

environment

and hospital

protocol.

Reference :

Nursing

fundamentals

( caring and

clinical

the patient

will be able to

achieve

improvement

of sleep

pattern as

evidenced by

patient’s

verbalization

of

improvement

in sleeping

pattern

washing or cleaning

her body before

going to sleep.

b. Encourage patient to

calm the mind by

replacing negative

thoughts with positive

affirmations or having

soft music to play.

c. Teach the patient to

have a quiet

Because stress,

anxiety, and

worry can lead to

an active mind at

bedtime. It is

essential to calm

the mind to

facilitate quality

sleep.

RENDER DUE

TO TIME

CONSTRAINT

S (Ms. MD is

discharged

already)

UNABLE TO

RENDER DUE

TO TIME

CONSTRAINT

S (Ms. MD is

discharged 121

decision

making ),

2004 Rick

Daniels; pp.

1315-1316

environment in

preparation for sleep.

To have restful

environment and

facilitate sleeping

already)

ASSESSMENT NURSING

DIAGNOSIS

RATIONALE GOALS INTERVENTION RATIONALE EVALUATION

Subjective:

““Medyo

nanghihina pa

ako, hindi pa

Self Care deficit

(self-toileting and

grooming)

Related to pain

Decrease

muscle tone

is the result

of the

SHORT TERM:

After 1 day of

nursing

intervention the

INDEPENDENT:

-Encourage

independence but

To decrease

frustrations in

SHORT TERM:

After 1 day of

nursing

intervention the

122

ako

masyadong

makakilos.

Katulad nito

hirap ako

pumunta sa

CR mag-isa

tsaka mag-palit

ng damit.

Lagkit na lagkit

na nga ako

eh.”as

verbalized by

and discomfort

As maniested by

Subjective:

““Medyo

nanghihina pa

ako, hindi pa ako

masyadong

makakilos.

Katulad nito hirap

ako pumunta sa

CR mag-isa

tsaka mag-palit

ng damit. Lagkit

decrease in

the oxygen

level of the

brain which

there is the

motor

function to

control the

movement of

the body, is

the result of

self care

deficit

because

patient will be

ale to perform

self care

activities within

the level of its

own ability and

identify

personal or

community

resources that

can provide

assistance.

intervene when

patient can not

perform.

-Provide safety

precautions

-Provide

appropriate

assistive devices

-Use consistence

in routines with

performing

activities

To avoid injury

It may enhance

self care abilities

This helps

patient to

patient was able

to perform self

care activities

within the level of

its own ability and

identified

personal or

community

resources that

can provide

assistance. “Ito

padischarge na

ako, kaya ko na

123

the patient

Objective:

-Inability to rise

from the toilet

or commode

-inability to get

toilet or

commode

-impaired

ability to obtain

or replace

articles of

clothing put on

na lagkit na nga

ako eh.”as

verbalized by the

patient.

Objective:

-Inability to rise

from the toilet or

commode

-inability to get

toilet or

commode

-impaired ability

to obtain or

replace articles of

there is the

decrease in

muscle tone

Reference:

Nursing care

plan by Meg

Gulanick

pg.53

her self care

activities

organize and

carry out self

care skills.

kumilos mag-isa.”

GOAL MET

LONG TERM:

UNABLE TO

RENDER DUE

TO TIME

CONSTRAINTS

(Ms. MD is

discharged

already)

124

or take off

necessary

items on lower

extremities.

clothing put on or

take off

necessary items

on lower

extremities.

125